Medical gas plasma technology: Roadmap on cancer treatment and immunotherapy

Despite continuous therapeutic progress, cancer remains an often fatal disease. In the early 2010s, first evidence in rodent models suggested promising antitumor action of gas plasma technology. Medical gas plasma is a partially ionized gas depositing multiple physico-chemical effectors onto tissues, especially reactive oxygen and nitrogen species (ROS/RNS). Today, an evergrowing body of experimental evidence suggests multifaceted roles of medical gas plasma-derived therapeutic ROS/RNS in targeting cancer alone or in combination with oncological treatment schemes such as ionizing radiation, chemotherapy, and immunotherapy. Intriguingly, gas plasma technology was recently unraveled to have an immunological dimension by inducing immunogenic cell death, which could ultimately promote existing cancer immunotherapies via in situ or autologous tumor vaccine schemes. Together with first clinical evidence reporting beneficial effects in cancer patients following gas plasma therapy, it is time to summarize the main concepts along with the chances and limitations of medical gas plasma onco-therapy from a biological, immunological, clinical, and technological point of view.

A Prospective Randomized Controlled Pilot Study to Assess the Response and Tolerability of Cold Atmospheric Plasma for Rosacea

INTRODUCTION

Rosacea is a common, facial, chronic inflammatory skin disease. Due to its complex pathogenesis, adequate therapy of rosacea can be challenging. An innovative recent therapeutic tool is cold atmospheric plasma (CAP), which is already established in the treatment of chronic wounds and promising in different other skin diseases.

METHODS

In a split-face pilot study we investigated dielectric-barrier-discharged CAP in erythemato-telangiectatic (ETR) and/or papulopustular rosacea (PPR). CAP treatment was applied on lesional skin of a randomized side once daily (90 s/area) for 6 weeks. The other untreated side served as control. Co-primary endpoints were ≥1 improvement of the Investigator Global Assessment (IGA) score on the treated side compared to control and a decline of the Dermatology Life Quality Index (DLQI) after 6 weeks. Secondary endpoints included inflammatory lesion count (papules and pustules), skin redness intensity and erythema size. Adverse events (AEs) were recorded constantly. Additionally, participants were weekly assessed for symptoms, skin condition, trigger factors, skin care, treatment success, and local tolerance parameters. All p values were calculated using the Wilcoxon signed-rank test.

RESULTS

Twelve subjects (ETR, n = 3; ETR and PPR, n = 9) completed the study. DLQI was significantly improved after 6 weeks (p = 0.007). On the CAP-treated side, lesions (p = 0.007) and erythema size (p = 0.041) were significantly reduced compared to the control. IGA (p = 0.2) and skin redness intensity (p = 0.5) did not differ significantly between control and CAP-treated side. No serious AEs occurred and treatment was well tolerated.

CONCLUSION

CAP is a promising new treatment of rosacea, especially for PPR.

Split-face comparison of hydroquinone 4% plus nitrogen plasma vs. hydroquinone 4% alone in the treatment of melasma

Treatment of skin diseases is important yet challenging. One of the most common skin diseases in women is melasma, which features acquired facial hyperpigmentation. We studied the effect of cold atmospheric nitrogen plasma on this disease. To characterize the nitrogen plasma, we obtained the relative intensity of the species and the plasma temperature and skin temperature during processing at different input powers and gas flows. Patients complaining of melasma were treated with hydroquinone on both sides of the face, and one side was randomly selected for additional nitrogen plasma therapy. Eight treatment sessions of plasma processing were provided 1 week apart, and one follow-up session was scheduled 1 month after the end of treatment. The rate of improvement was scored by a dermatologist in the eighth session and 1 month following the last session using the modified Melasma Area Severity Index (mMASI). Skin biomechanical characteristics such as melanin, cutaneous resonance running time (CRRT), transepidermal water loss (TEWL), and hydration were measured at baseline and during the fourth, eighth, and follow-up sessions. On both sides, we observed a significant decrease in both CRRT and melanin (P < 0.05). TEWL did not change on both sides, while hydration decreased significantly only on the side to which hydroquinone was applied in isolation (P < 0.05). According to clinical scores, on both sides, we had significant improvement. On the side that plasma was not applied, the percentage reduction of pigmentation (mMASI) in the eighth and follow-up sessions in comparison with the baseline was 5.49 ± 8.50% and 33.04 ± 9.17%, respectively, while on the other side, these figures were 20.57 ± 6.64% and 48.11 ± 11%. For melanin, these figures were 13.84 ± 4.84% and 18.23 ± 7.10% on the hydroquinone side and 21.56 ± 3.13% and 23.93 ± 3.02% on the other side. According to these results, nitrogen plasma can safely complement topical hydroquinone to improve clinical outcomes when treating melasma without causing stratum corneum damage or skin discomfort, though confirmatory studies are needed.

Topically Confined Enhancement of Cutaneous Microcirculation by Cold Plasma

INTRODUCTION

We aim to explore potentials and modalities of cold atmospheric pressure plasma (CAP) for the subsequent development of therapies targeting an increased perfusion of the lower leg skin tissue. In this study, we addressed the question whether the microcirculation enhancement is restricted to the tissue in direct contact with plasma or if adjacent tissue might also benefit.

METHODS

A dielectric barrier discharge (DBD)-generated CAP device exhibiting an electrode area of 27.5 cm2 was used to treat the anterior lower leg of ten healthy subjects for 4.5 min. Subsequently, hyperspectral imaging was performed to measure the tempospatially resolved characteristics of microcirculation parameters in superficial (up to 1 mm) and deeper (up to 5 mm) skin layers.

RESULTS

In the tissue area covered by the plasma electrode, DBD-CAP treatment enhances most of the perfusion parameters. The maximum oxygen saturation increase reached 8%, the near-infrared perfusion index (NIR) increased by a maximum of 4%, and the maximum tissue hemoglobin increase equaled 14%. Tissue water index (TWI) was lower in both the control and the plasma groups, thus not affected by the DBD-CAP treatment. Yet, our study reveals that adjacent tissue is hardly affected by the enhancements in the electrode area, and the effects are locally confined.

CONCLUSION

Application of DBD-CAP to the lower leg resulted in enhancement of cutaneous microcirculation that extended 1 h beyond the treatment period with localization to the tissue area in direct contact with the cold plasma. This suggests the possibility of tailoring application schemes for topically confined enhancement of skin microcirculation, e.g., in the treatment of chronic wounds.

Conductivity augments ROS and RNS delivery and tumor toxicity of an argon plasma jet

Gas plasma jet technology was recently identified as a potential adjuvant in the palliation of cancer patients. However, a practical point raised is if higher therapeutic efficacy is achieved with the gas plasma applied in direct contact to the tumor tissue (conducting) or during treatment with the remote cloud of reactive oxygen and nitrogen species (ROS/RNS) being expelled. In a bedside-to-bench study, this clinical question was translated into studying these two distinct treatment modalities using a three-dimensional tumor cell-matrix-hydrogel assay with subsequent quantitative confocal imaging. Z-resolved fluorescence analysis of two cancer cell lines revealed greater toxicity of the conducting mode. This result was re-iterated in the growth analysis of vascularized tumor tissue cultured on chicken embryos' CAM using in ovo bioluminescence imaging. Furthermore, for conducting compared to free mode, optical emission spectroscopy revealed stronger RNS signal lines in the gas phase, while both ROS/RNS deposition in the liquid was drastically exacerbated in the conducting mode. Altogether, our results are vital in understanding the importance of standardized treatment distances on the therapeutic efficacy of gas plasma exposure in clinical oncology and will help to give critical implications for clinicians involved in plasma onco-therapy in the future.

Medical gas plasma-stimulated wound healing: Evidence and mechanisms

Defective wound healing poses a significant burden on patients and healthcare systems. In recent years, a novel reactive oxygen and nitrogen species (ROS/RNS) based therapy has received considerable attention among dermatologists for targeting chronic wounds. The multifaceted ROS/RNS are generated using gas plasma technology, a partially ionized gas operated at body temperature. This review integrates preclinical and clinical evidence into a set of working hypotheses mainly based on redox processes aiding in elucidating the mechanisms of action and optimizing gas plasmas for therapeutic purposes. These hypotheses include increased wound tissue oxygenation and vascularization, amplified apoptosis of senescent cells, redox signaling, and augmented microbial inactivation. Instead of a dominant role of a single effector, it is proposed that all mechanisms act in concert in gas plasma-stimulated healing, rationalizing the use of this technology in therapy-resistant wounds. Finally, addressable current challenges and future concepts are outlined, which may further promote the clinical utilization, efficacy, and safety of gas plasma technology in wound care in the future.

The Response and Tolerability of a Novel Cold Atmospheric Plasma Wound Dressing for the Healing of Split Skin Graft Donor Sites: A Controlled Pilot Study

INTRODUCTION

Cold atmospheric plasma (CAP) has positive effects on wound healing and antimicrobial properties. However, an ongoing challenge is the development of specific modes of application for different clinical indications.

OBJECTIVES

We investigated in a prospective pilot study the response and tolerability of a newly developed CAP wound dressing for the acute healing of split skin graft donor sites compared to conventional therapy.

METHODS

We applied both treatments to each patient (n = 10) for 7 days and measured 4 parameters of wound healing every other day (i.e., 1,440 measurements) using a hyperspectral imaging camera. Additionally, we evaluated the clinical appearance and pain levels reported by the patients.

RESULTS

The CAP wound dressing was superior to the control (p < 0.001) in the improvement of 3 wound parameters, that is, deep tissue oxygen saturation, hemoglobin distribution, and tissue water distribution. CAP was well tolerated, and pain levels were lower in CAP-treated wound areas.

CONCLUSION

CAP wound dressing is a promising new tool for acute wound healing.

Tumor cell metabolism correlates with resistance to gas plasma treatment: The evaluation of three dogmas

Gas plasma is a partially ionized gas increasingly recognized for targeting cancer. Several hypotheses attempt to explain the link between plasma treatment and cytotoxicity in cancer cells, all focusing on cellular membranes that are the first to be exposed to plasma-generated reactive oxygen species (ROS). One proposes high levels of aquaporins, membrane transporters of water and hydrogen peroxide, to mark tumor cell line sensitivity to plasma treatment. A second focuses on membrane-expression of redox-related enzymes such as NADPH oxidases (NOX) that may modify or amplify the effects of plasma-derived ROS, fueling plasma-induced cancer cell death. Another hypothesis is that the decreased cholesterol content of tumor cell membranes sensitizes these to plasma-mediated oxidation and subsequently, cytotoxicity. Screening 33 surface molecules in 36 tumor cell lines in correlation to their sensitivity to plasma treatment, the expression of aquaporins or NOX members could not explain the sensitivity but were rather associated with treatment resistance. Correlation with transporter or enzyme activity was not tested. Analysis of cholesterol content confirmed the proposed positive correlation with treatment resistance. Strikingly, the strongest correlation was found for baseline metabolic activity (Spearman r = 0.76). Altogether, these data suggest tumor cell metabolism as a novel testable hypothesis to explain cancer cell resistance to gas plasma treatment for further elucidating this innovative field's chances and limitations in oncology.

Gas plasma-spurred wound healing is accompanied by regulation of focal adhesion, matrix remodeling, and tissue oxygenation

In response to injury, efficient migration of skin cells to rapidly close the wound and restore barrier function requires a range of coordinated processes in cell spreading and migration. Gas plasma technology produces therapeutic reactive species that promote skin regeneration by driving proliferation and angiogenesis. However, the underlying molecular mechanisms regulating gas plasma-aided cell adhesion and matrix remodeling essential for wound closure remain elusive. Here, we combined in vitro analyses in primary dermal fibroblasts isolated from murine skin with in vivo studies in a murine wound model to demonstrate that gas plasma treatment changed phosphorylation of signaling molecules such as focal adhesion kinase and paxillin α in adhesion-associated complexes. In addition to cell spreading and migration, gas plasma exposure affected cell surface adhesion receptors (e.g., integrinα5β1, syndecan 4), structural proteins (e.g., vinculin, talin, actin), and transcription of genes associated with differentiation markers of fibroblasts-to-myofibroblasts and epithelial-to-mesenchymal transition, cellular protrusions, fibronectin fibrillogenesis, matrix metabolism, and matrix metalloproteinase activity. Finally, we documented that gas plasma exposure increased tissue oxygenation and skin perfusion during ROS-driven wound healing. Altogether, these results provide critical insights into the molecular machinery of gas plasma-assisted wound healing mechanisms.

The molecular and physiological consequences of cold plasma treatment in murine skin and its barrier function

Cold plasma technology is an emerging tool facilitating the spatially controlled delivery of a multitude of reactive species (ROS) to the skin. While the therapeutic efficacy of plasma treatment has been observed in several types of diseases, the fundamental consequences of plasma-derived ROS on skin physiology remain unknown. We aimed to bridge this gap since the epidermal skin barrier and perfusion plays a vital role in health and disease by maintaining homeostasis and protecting from environmental damage. The intact skin of SKH1 mice was plasma-treated in vivo. Gene and protein expression was analyzed utilizing transcriptomics, qPCR, and Western blot. Immunofluorescence aided the analysis of percutaneous skin penetration of curcumin. Tissue oxygenation, perfusion, hemoglobin, and water index was investigated using hyperspectral imaging. Reversed-phase liquid-chromatography/mass spectrometry was performed for the identification of changes in the lipid composition and oxidation. Transcriptomic analysis of plasma-treated skin revealed modulation of genes involved in regulating the junctional network (tight, adherence, and gap junctions), which was confirmed using qPCR, Western blot, and immunofluorescence imaging. Plasma treatment increased the disaggregation of cells in the stratum corneum (SC) concomitant with increased tissue oxygenation, gap junctional intercellular communication, and penetration of the model drug curcumin into the SC preceded by altered oxidation of skin lipids and their composition in vivo. In summary, plasma-derived ROS modify the junctional network, which promoted tissue oxygenation, oxidation of SC-lipids, and restricted penetration of the model drug curcumin, implicating that plasma may provide a novel and sensitive tool of skin barrier regulation.

Plasma medicine for neuroscience-an introduction

Plasma is an ionized gas. It is typically formed at high temperature. As a result of both the development of low-temperature plasma sources and a better understanding of complex plasma phenomena over the last decade, "plasma medicine" has become a booming interdisciplinary research topic of growing importance that explores enormous opportunities at the interface of chemistry, plasma physics, and biomedical sciences with engineering. This review presents the latest development in plasma medicine in the area of the central nervous system and aims to introduce cutting-edge plasma medicine to clinical and translational medical researchers and practitioners.

New insights on molecular internalization and drug delivery following plasma jet exposures

In this study, we evaluated cold atmospheric plasmas as a physical drug delivery tool for human cervical cancer HeLa cells and murine breast carcinoma 4T1 cells. Different cell exposure protocols - plasma jet, plasma treated medium, and combinations of plasma-induced electric field and plasma treated medium- have been proposed and assessed to provide new insight on plasma-induced uptake mechanism. Cell culture medium composition and volume are key parameters to achieve an efficient molecular uptake. The plasma device enabled the delivery of molecules having 150 kDa-size into 4T1cells. For the first time to our knowledge, substance uptake kinetics after plasma treatment were investigated. The percentage of positive cells for propidium iodide and an anti-cancer agent, doxorubicin, was higher when the drugs were added a few minutes after treatment. The Plasma treated medium was not found to be as efficient as direct plasma treatment in 4T1 cells while allowing an efficient delivery in HeLa cells. Uptake levels as high as 39.3 ± 2.9% and 40.1 ± 9.5% for HeLa and 4 T1 cells respectively were achieved for optimized operating conditions, for which the viability of the cells was not severely affected. We also observed that plasma treatment induced the formation of actin stress fibers into cells revealing a mechanical stress.

Controlling stem cell fate using cold atmospheric plasma

The stem cell is the foundation of regenerative medicine and tissue engineering. Regulating specific stem cell fate, such as cell attachment, proliferation, differentiation, and even death, undergoes continuous development. Cold atmospheric plasma (CAP), the core technology of plasma medicine, is attracting tremendous attention due to its ability and versatility to manipulate various types of cells, including stem cells. Specifically, the direct and indirect applications of CAP in controlling cell fate are best exemplified by upfront irradiation of the stem cells and modification of the stem cell niche, respectively. This review will describe the recent advances in various CAP strategies, both direct and indirect, and their influence on the fate of healthy and cancer stem cells. Particular emphasis will be placed on the mechanism of connecting the physical and chemical cues carried by the plasma and biological changes presented by the cells, especially at the transcriptomic level. The ultimate goal is to exploit CAP’s potential in regenerative medicine.

[Current indications for plasma therapy in dermatology]

BACKGROUND

Plasma medicine is gaining increasing interest and provides a multitude of dermatological applications. Cold atmospheric pressure plasma (CAP) can be used in clinical applications without harming the treated tissue or in a tissue destructive manner. It consists of a complex mixture of biologically active agents, which can act synergistically on the treated material or tissue.

OBJECTIVES

A summary of the current research findings regarding dermatological applications of CAP is provided.

METHODS

Literature on CAP applications in dermatology has been screened and summarized.

RESULTS

CAP exerts antimicrobial, tissue-stimulating, blood-flow-stimulating but also pro-apoptotic effects. By exploiting these properties, CAP is successfully applied for disinfection and treatment of chronic ulcerations. Furthermore, positive effects of CAP have been shown for the treatment of tumors, actinic keratosis, scars, ichthyosis, atopic eczema as well as for alleviation of pain and itch.

CONCLUSIONS

While the use of CAP for disinfection and wound treatment has already moved into clinical practice, further applications such as cancer treatment are still exploratory.

Plasma Permeabilization of Human Excised Full-Thickness Skin by µs- and ns-pulsed DBD

INTRODUCTION

Cold atmospheric plasma (CAP) is gaining increasing importance as a medical or cosmetic treatment for various indications. The technology is best suited to the treatment of surfaces such as the skin and is already used in wound care and, in exemplary case studies, the reduction of superficial tumors. Several plasma sources have been reported to affect the skin barrier function and potentially enable drug delivery across or into plasma-treated skin.

OBJECTIVE

In this study, this effect was quantified for different plasma sources in order to elucidate the influence of voltage rise time, pulse duration, and power density in treatments of full-thickness skin.

METHODS

We compared three different dielectric barrier discharges (DBDs) as to their permeabilization efficiency using Franz diffusion cell permeation experiments and measurements of the transepithelial electrical resistance (TEER) with full-thickness human excised skin.

RESULTS

We found a significant reduction of the TEER for all three plasma sources. Permeation of the hydrophilic sodium fluorescein molecule was enhanced by a factor of 11.7 (low power) to 41.6 (high power) through µs-pulsed DBD-treated skin. A smaller effect was observed after treatment with the ns-pulsed DBD.

CONCLUSIONS

The direct treatment of excised human full-thickness skin with CAP, specifically a DBD, can lead to pore formation and enhances transdermal transport of sodium fluorescein.

xCT (SLC7A11) expression confers intrinsic resistance to physical plasma treatment in tumor cells

Cold physical plasma is a partially ionized gas investigated as a new anticancer tool in selectively targeting cancer cells in monotherapy or in combination with therapeutic agents. Here, we investigated the intrinsic resistance mechanisms of tumor cells towards physical plasma treatment. When analyzing the dose-response relationship to cold plasma-derived oxidants in 11 human cancer cell lines, we identified four 'resistant' and seven 'sensitive' cell lines. We observed stable intracellular glutathione levels following plasma treatment only in the 'resistant' cell lines indicative of altered antioxidant mechanisms. Assessment of proteins involved in GSH metabolism revealed cystine-glutamate antiporter xCT (SLC7A11) to be significantly more abundant in the 'resistant' cell lines as compared to 'sensitive' cell lines. This decisive role of xCT was confirmed by pharmacological and genetic inhibition, followed by cold physical plasma treatment. Finally, microscopy analysis of ex vivo plasma-treated human melanoma punch biopsies suggested a correlation between apoptosis and basal xCT protein abundance. Taken together, our results demonstrate that xCT holds the potential as a biomarker predicting the sensitivity of tumor cells towards plasma treatment.

Plasma Medicine: A Field of Applied Redox Biology

Plasma medicine comprises the application of physical plasma directly on or in the human body for therapeutic purposes. Three most important basic plasma effects are relevant for medical applications: i) inactivation of a broad spectrum of microorganisms, including multidrug-resistant pathogens, ii) stimulation of cell proliferation and angiogenesis with lower plasma treatment intensity, and iii) inactivation of cells by initialization of cell death with higher plasma treatment intensity, above all in cancer cells. Based on own published results as well as on monitoring of relevant literature the aim of this topical review is to summarize the state of the art in plasma medicine and connect it to redox biology. One of the most important results of basic research in plasma medicine is the insight that biological plasma effects are mainly mediated via reactive oxygen and nitrogen species influencing cellular redox-regulated processes. Plasma medicine can be considered a field of applied redox biology.

Effects of Plasma Activated Medium on Head and Neck FaDu Cancerous Cells: Comparison of 3D and 2D Response

OBJECTIVE

The aim of this work is to investigate the inhibitory effect of Plasma Activated Medium (PAM) on Head and Neck cancerous cells (FaDu). The response of FaDu cells in monolayer cultures and Multi Cellular Tumor Spheroids (MCTS) after treatment with different PAMs will be compared.

BACKGROUND

Head and Neck squamous cell carcinoma is a widespread cancer that responds poorly to anticancer treatments such as chemotherapy and radiotherapy. Nowadays there is a growing interest in cold plasmas and their applications in cancer therapy.

METHODS

A homemade helium plasma jet is used to produce PAM. The effects of PAM and hydrogen peroxide H₂O₂ on FaDu 2D cells cultures and MCTS were characterized by evaluating the cell viability with PrestoBlue test and by measuring the size of MCTS.

RESULTS

One treatment with PAM induce cell detachment from MCTS since the first day in a PAM exposure dependent manner. This is due to the presence of H₂O₂ in PAM. However, a rapid spheroids regrowth is observed attributed to a resistance of FaDu cells to H₂O₂. After multiple treatments of MCTS with PAM we obtained an inhibition of cell growth. MCTS are brought out when comparing PAM effect on 2D versus MCTS. Inversely, PAM induces cell death in the case of 2D cell culture.

CONCLUSION

PAM may be considered as a potentially efficient agent in the therapy of head and neck cancer. We also point out that MCTS is a more valuable model than 2D cell culture for the evaluation of the anti-cancer activity of PAM.

Long-lived and short-lived reactive species produced by a cold atmospheric pressure plasma jet for the inactivation of Pseudomonas aeruginosa and Staphylococcus aureus

Different chemical pathways leading to the inactivation of Pseudomonas aeruginosa and Staphylococcus aureus by a cold atmospheric pressure plasma jet (APPJ) in buffered and non-buffered solutions are reported. As APPJs produce a complex mixture of reactive species in solution, a comprehensive set of diagnostics were used to assess the liquid phase chemistry. This includes absorption and electron paramagnetic resonance spectroscopy in addition to a scavenger study to assess the relative importance of the various plasma produced species involved in the inactivation of bacteria. Different modes of inactivation of bacteria were found for the same plasma source depending on the solution and the plasma feed gas. The inactivation of bacteria in saline is due to the production of short-lived species in the case of argon plasma when the plasma touches the liquid. Long-lived species (ClO^-) formed by the abundant amount of O^. radicals produced by the plasmas played a dominant role in the case of Ar + 1% O₂ and Ar + 1% air plasmas when the plasma is not in direct contact with the liquid. Inactivation of bacteria in distilled water was found to be due to the generation of short-lived species: O^. &O₂^.- for Ar + 1% O₂ plasma and O₂^.- (and ^.OH in absence of saline) for Ar plasma.

Does antibiotic resistance impair plasma susceptibility of multi-drug resistant clinical isolates of enterococci in vitro?

Background

Cold atmospheric plasma could constitute an alternative against multi-drug resistant pathogens. Susceptibility of enterococci to cold atmospheric plasma was investigated in vitro.

Methods

39 clinical isolates of enterococci were grouped dependent on the most important resistance patterns and treated on agar using dielectric barrier discharge plasma. These included enterococci with combined vancomycin- and high-level gentamicin resistance, high-level resistance to gentamicin (HLGR) only, vancomycin resistance alone (VRE), and enterococci susceptible to both. Susceptibility to cold atmospheric plasma was evaluated based on the zones of inhibition and examined in terms of the enterococcal group and the “degree” of drug resistance.

Results

Cold atmospheric plasma treatment killed all groups. Comparison of VRE and HLGR strains with non-VRE and non-HLGR isolates concerning zones of inhibition revealed that enterococci with special resistance patterns (VRE and HLGR) showed significantly smaller zones of inhibition than the sensitive ones. The mean of all isolates, irrespective of belonging to groups, showed smaller zones of inhibition with increasing “degree” of drug resistance.

Conclusions

Cold atmospheric plasma treatment killed all isolates of enterococci, but its efficacy depended on the “degree” of drug resistance and on membership in special resistance groups with particular clinical-outbreak importance. However, a possible role of the different genetic lineages, which might be prone to acquiring more or less resistance phenotypes, may also play a role in this context.

Electronic supplementary material

The online version of this article (doi:10.1186/s13099-016-0122-4) contains supplementary material, which is available to authorized users.

Investigation of plasma induced electrical and chemical factors and their contribution processes to plasma gene transfection

This study has been done to know what kind of factors in plasmas and processes on cells induce plasma gene transfection. We evaluated the contribution weight of three groups of the effects and processes, i.e. electrical, chemical and biochemical ones, inducing gene transfection. First, the laser produced plasma (LPP) was employed to estimate the contribution of the chemical factors. Second, liposomes were fabricated and employed to evaluate the effects of plasma irradiation on membrane under the condition without biochemical reaction. Third, the clathrin-dependent endocytosis, one of the biochemical processes was suppressed. It becomes clear that chemical factors (radicals and reactive oxygen/nitrogen species) do not work by itself alone and electrical factors (electrical current, charge and field) are essential to plasma gene transfection. It turned out the clathrin-dependent endocytosis is the process of the transfection against the 60% in all the transfected cells. The endocytosis and electrical poration are dominant in plasma gene transfection, and neither permeation through ion channels nor chemical poration is dominant processes. The simultaneous achievement of high transfection efficiency and high cell survivability is attributed to the optimization of the contribution weight among three groups of processes by controlling the weight of electrical and chemical factors.

Low-temperature atmospheric-pressure plasma sources for plasma medicine

In this review paper, fundamental overviews of low-temperature atmospheric-pressure plasma generation are provided and various sources for plasma medicine are described in terms of operating conditions and plasma properties.

Antibacterial efficacy of a novel plasma reactor without an applied gas flow against methicillin resistant Staphylococcus aureus on diverse surfaces

The use of nonthermal plasma in the clinic has gained recent interest, as the need for alternative or supplementary strategies are necessary for preventing multi-drug resistant infections. The purpose of this study was to evaluate the antibacterial efficacy of a novel plasma reactor based on a high current version of sliding discharge and operated by nanosecond voltage pulses without an applied gas flow. This modification is advantageous for both portability and convenience. Bacterial inactivation was determined within a chamber by direct quantification of colony Jing units. Plasma exposure significantly inhibited the growth of Escherichia coli and Staphylococcus epidermidis following a 1-min application (p<0.001). S. epidermidis was more susceptible to the plasma after a 5-min exposure compared to E. coli. Temperature and pH measurements taken immediately before and after plasma exposure determined neither heat nor pH changes play a role in bacterial inactivation. Because of the notable effect on S. epidermidis, the effect of plasma exposure on several isolates and strains of the related opportunistic pathogen Staphylococcus aureus was quantified. While S. aureus isolates and strains were efficiently inactivated on an agar surface, subsequent testing on other clinically relevant surfaces demonstrated that the inactivation level, although significant, was reduced. This reduction appeared to depend on both the surface texture and the surface moisture content. These findings suggest this novel plasma source lacking an applied gas flow has potential application for surface bacterial decontamination.

Bactericidal efficacy of atmospheric pressure non-thermal plasma (APNTP) against the ESKAPE pathogens

The emergence of multidrug-resistant pathogens within the clinical environment is presenting a mounting problem in hospitals worldwide. The 'ESKAPE' pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacter spp.) have been highlighted as a group of causative organisms in a majority of nosocomial infections, presenting a serious health risk due to widespread antimicrobial resistance. The stagnating pipeline of new antibiotics requires alternative approaches to the control and treatment of nosocomial infections. Atmospheric pressure non-thermal plasma (APNTP) is attracting growing interest as an alternative infection control approach within the clinical setting. This study presents a comprehensive bactericidal assessment of an in-house-designed APNTP jet both against biofilms and planktonic bacteria of the ESKAPE pathogens. Standard plate counts and the XTT metabolic assay were used to evaluate the antibacterial effect of APNTP, with both methods demonstrating comparable eradication times. APNTP exhibited rapid antimicrobial activity against all of the ESKAPE pathogens in the planktonic mode of growth and provided efficient and complete eradication of ESKAPE pathogens in the biofilm mode of growth within 360s, with the exception of A. baumannii where a >4log reduction in biofilm viability was observed. This demonstrates its effectiveness as a bactericidal treatment against these pathogens and further highlights its potential application in the clinical environment for the control of highly antimicrobial-resistant pathogens.

Impact of non-thermal plasma treatment on MAPK signaling pathways of human immune cell lines

In the field of wound healing research non-thermal plasma (NTP) increasingly draws attention. Next to its intensely studied antibacterial effects, some studies already showed stimulating effects on eukaryotic cells. This promises a unique potential in healing of chronic wounds, where effective therapies are urgently needed. Immune cells do play an important part in the process of wound healing and their reaction to NTP treatment has yet been rarely examined. Here, we studied the impact of NTP treatment using the kinpen on apoptotic and proliferative cell signaling pathways of two human immune cell lines, the CD4(+)T helper cell line Jurkat and the monocyte cell line THP-1. Depending on NTP treatment time the number of apoptotic cells increased in both investigated cell types according to a caspase 3 assay. Western blot analysis pointed out that plasma treatment activated pro-apoptotic signaling proteins like p38 mitogen-activated protein kinase (p38 MAPK) and c-Jun N-terminal kinase 1 and 2 (JNK 1/2) in both cell types. Stronger signals were detected in Jurkat cells at comparable plasma treatment times. Intriguingly, exposure of Jurkat and THP-1 cells to plasma also activated the pro-proliferative signaling molecules extracellular signal-regulated kinase 1/2 (ERK 1/2) and MAPK/ERK kinase 1 and 2 (MEK 1/2). In contrast to Jurkat cells, the anti-apoptotic heat shock protein 27 (HSP27) was activated in THP-1 cells after plasma treatment, indicating a possible mechanism how THP-1 cells may reduce programmed cell death. In conclusion, several signaling cascades were activated in the examined immune cell lines after NTP treatment and in THP-1 monocytes a possible defense mechanism against plasma impacts could be revealed. Therefore, plasma might be a treatment option for wound healing.